AFFECTING CALCIUM/
BONE RESORPTION
BONE RESORPTION
This vitamin helps to increase Calcium levels in the blood serum by enhancing its absorption in the small intestine + increasing its reabsorption in kidneys, ultimately promoting bone mineralization:
(a) Vitamin A
(b) Vitamin B12
(c) Vitamin C
(d) Vitamin D
(e) Folate
(D) VITAMIN D
NOTE: The recommended daily allowance (RDA) of Vit D is 15 mcg/day (ages 1-70) or 20 mcg/day (those of ages 70+)
The prototype baclofen (Gablofen) is a GABA derivative that reduces the influx of calcium into spinal neurons, reducing the presynaptic neurotransmitter release in the excitatory pathways. As a net effect, it seems to
reduce impulse transmission
from the spinal cord to ________ muscles,
suppressing hyperactive reflexes
BONUS: Explain why that's a good thing for some people
Reduces impulse transmission to SKELETAL muscles
BONUS: *Relieves spasms for people with MS and some SCI.
*Decreases discomfort of spasticity
*Increases performance [for people with MS and some with SCI] by decreasing flexor and extensor spasms; by decreasing associated pain; by decreasing muscle rigidity; and by
suppressing resistance to passive movement.
The drug etanercept (Enbrel) works by getting the immune mediator TNF to bind with it instead of its normal receptor sites on cells within joint synovia.
As a result, for patients with moderate to severe Rheumatoid Arthritis (R.A.), it can produce
THIS NET EFFECT
DECREASE THE INFLAMMATORY PROCESS WITHIN THE JOINTS of a person with RA + those with other types of arthritis, plaque psoriasis, and ankylosing spondylitis
TRUE OR FALSE: The purpose of the drug allopurinol (Zyloprim) is to reduce the pain a patient may feel associated with a flare of gout symptoms
FALSE
For a patient with gout, the net effect of allopurinol (ZYLOPRIM) is to reduce serum uric acid levels, preventing gout or treating gouty arthritis with joint pain and inflammation, but it make take MONTHS,
so it is NOT designed to reduce pain that may occur
during acute exacerbations
TRUE OR FALSE: Rheumatoid Arthritis (R.A.) causes an autoimmune process in which a person's own immune system attacks the synovial tissue in their own joints, leading joints to become swollen, tender, and warm, and eventually destroyed altogether via bone on bone damage and joints fusing
TRUE
NOTE: Aside from Disease Modifying Anti-Rheumatic Drugs (DMARDs) like methotrexate (Otrexup) and etanercept (Enbrel), a person with R.A. might also be treated with NSAIDs or Corticosteroids/Glucocorticoids to attempt to reduce inflammation caused by the disease
For patients with hypocalcemia, their blood level of calcium can be supplemented by giving them Calcium directly. In what routes can it be administered to the body (SELECT ALL THAT APPLY)?
(a) PO
(b) sub Q
(c) IM
(d) IV
(A) PO and (D) IV
Note: IV-delivered calcium can irritate the tissues, so extra care must be taken when giving it via the IV route.
TRUE OR FALSE: baclofen (Gablofen) is a muscle relaxer that (as an AE) can make a person dizzy, drowsy, tired and weak, and in addition can raise a person's
blood glucose levels.
TRUE
Common AEs also include confusion, HA, insomnia, hypotension, n/v, constipation, and urinary frequency.
NOTE: Although it can make a person feel weak as an AE, it does not itself decrease muscle strength
Which is the "first line" drug for the treatment of RA, etanercept (Enbrel) or methotrexate (Otrexup)?
BONUS: Why?
methotrexate (Otrexup) is the 1st line drug
BONUS: Because of its efficacy, relative safety, low cost, and extensive use
TRUE OR FALSE: The drug allopurinol (Zyloprim) should be taken before breakfast and on an empty stomach, for if taken with food its effect will be greatly reduced
FALSE
The drug allopurinol (Zyloprim) is taken PO and SHOULD be taken with food -- and
lots of water as well! -- in order to
ENHANCE and improve the drug's absorption
NAME TWO OTHER conditions, besides gout, that the drug allopurinol (Zyloprim) may sometimes be used to treat
(1) KIDNEY STONES that result from a high uric acid level (only certain types of stones)
(2) TUMOR LYSIS SYNDROME in certain cancer patients that sometimes occurs as tumors break down under chemo and thereby increase uric acid levels in the blood
Name the prototype drug -- both the generic and Trade name of it -- that can be used to inhibit calcium resorption from bone by decreasing the ACTIVITY of osteoclasts (cells that break down bone)
alendronate (FOSAMAX)
Using the Trade name of the drug, one way to help remember its name is that the drug helps
bones in the body to become more like
"FOSSILS... to the max!" (Fosa-max)
Name the prototype (generic and Trade) of the muscle relaxer in this unit derived from a Tricyclic Antidepressant (TCA) that acts more in the brain stem to help relieve LOCALIZED spasms, and the pain associated with those localized spasms
BONUS: Is this drug effective for spasticity (Y/N)?
cyclobenzaprine (Flexeril)
BONUS: NO, this drug is INEFFECTIVE for the treatment of spasticity. It is just for acute localized muscle SPASMS
While on etanercept (Enbrel), a patient is at higher risk for infections, so the nurse should monitor for s/s of infection; the patient is at higher risk for malignancies such as lymphoma, so that needs to be monitored for as well; finally, this drug can be hard on the LIVER,
so the nurse should monitor...?
SIGNS AND SYMPTOMS OF HEPATIC (LIVER) FAILURE:
Jaundice, fatigue, anorexia, nausea, yellow eyes, dark urine. [Also the nurse should probably monitor Liver Function Tests, too!...]
The drug is contraindicated in patients with existing liver dysfunction or with a Hep B infection,
and if those with HF and/or poorly-controlled DM
When a patient is taking allopurinol (Zyloprim), they should avoid consuming alcohol, organ meats, legumes, or gravy. WHY?
THESE FOODS ARE HIGH IN PURINES, the substance that the body converts into uric acid
So eating these foods is counter-productive to the action of the drug (which is to inhibit the enzyme that converts purines into uric acid)
One of the patient teachings for baclofen (Gablofen) is that the patient should not stop taking it abruptly (no matter what method of administration). EXPLAIN WHY
ADVERSE EFFECTS FROM ABRUPT WITHDRAWAL:
(1) Abrupt withdrawal from the PO version can cause visual hallucinations, paranoid ideation, and seizures;
(2) Abrupt withdrawal from the intrathecal version can cause hyperthermia, rebound spasticity, rhabdomyolysis, Multiple Organ Dysfunction Syndrome (MODS), and even death
Name the prototype drug, both the generic and Trade name of it -- that can be used to increase bone density and decrease fracture risk by mimicking the effect of estrogen on bone (i.e. decreasing the PROLIFERATION of osteoclasts)
raloxifene (EVISTA)
Note: It also imitates other effects of estrogen, such as lowering blood levels of LDL and increasing the effectiveness of blood clotting (the latter of which increases the risk for thrombo-embolic events)
Because cyclobenzaprine (Flexeril) is a derivative of a Tricyclic Antidepressant (TCA), that tells us several things about the Adverse Effects, Drug Interactions, and Patient Teaching
to expect from this drug.
LIST AT LEAST THREE ASPECTS
common to many TCAs seen in this drug
(1) Anticholinergic effects: Dry mouth,
blurred vision, urinary retention, constipation, sinus tachy
(2) Cardiac rhythm disturbances
(3) Interactions with MANY other antidepressants (avoid)
(4) Avoid ETOH and other CNS depressants
(5) Do not operate heavy machinery
(6) Risk for serotonin syndrome
What is the Mechanism of Action (MOA) of the prototype drug methotrexate (Otrexup), and as a result of this MOA, what essential vitamin is the recipient encouraged to
take as a supplement?
FOLATE ANTAGONIST
Folate is also known as folic acid, aka Vitamin B9.
Blocking it seems to reduce the activity of T and B lymphocytes (WBCs) that are key to the autoimmune response of RA. Still, folate is necessary for DNA synthesis/cellular replication throughout the body, so modest folic acid (B9) supplementation is recommended.
List AT LEAST FOUR common Adverse Effects of allopurinol (Zyloprim)
(1) Nausea
(2) Vomiting
(3) Diarrhea
(4) Abdominal discomfort
(5) Drowsiness
(6) Headache
(7) Metallic taste
Which of the drugs in this week's unit requires SPECIAL HANDLING INSTRUCTIONS, namely the person administering the drug (be the the nurse, the caregiver, or the patient themselves) needs to WEAR THICK GLOVES?
BONUS: Why?
raloxifene (EVISTA)
(the Selective Estrogen Receptor Modulator)
BONUS: It is because the drug can be absorbed through the skin, and like with estrogen, can cause hormonal effects and/or fetal harm (teratogenic effect) in a person who is pregnant
Keep in mind that alendronate (Fosamax) should be only taken short term, for if taken longer term (or at higher doses) the following 3 rare serious side effects can occur --
LIST ALL THREE
Rare serious side effects -- especially with long term therapy -- include:
(1) OCULAR INFLAMMATION
(2) OSTEONECROSIS OF THE JAW
(3) ATYPICAL FEMUR FRACTURES
The muscle relaxer baclofen (Gablofen) can be administered PO (3x or 4x/day), but it also can be administered by
THIS other route
INTRATHECAL
(i.e. via an implantable pump in the abdomen that places the drug directly in the cervical-spinal fluid (CSF)
as it circulates
around the spinal cord)
LIST AT LEAST FIVE important bullet points that should be part of the nurse's teaching/ Patient Education for the drug methotrexate (Otrexup)
*Report s/s of infection;
*Report s/s of bone marrow suppression;
*Report s/s of liver damage (hepatotoxicity or hepatic fibrosis) or kidney damage;
*Drug causes increased sun sensitivity: wear sunscreen;
*Take the PO version with food to avoid GI upset;
*Use soft toothbrush due to risk for oral mucositis;
*Recommend supplement diet with folic acid (Vit B9);
*Therapeutic effects of this drug are slow to develop (approx 3-6 weeks), so be patient
*Do not take together with active vaccines, discontinue before vaccine injections
If rash or fever develops in a patient taking allopurinol (Zyloprim), the medication should be discontinued immediately, due to the possibility that these symptoms are caused by THIS rare syndrome (NAME IT)
ALLOPURINOL HYPERSENSITIVITY SYNDROME (A.H.S.)
s/s include: rash, fever, low eosinophils (measured in a CBC), as well as liver and kidney dysfunction.
Which of the drugs in this week's unit is listed on the BEERS criteria as potentially being inappropriate for older adults (because of its unsafe effects in the elderly)?
cyclobenzaprine (Flexeril)
(The TCA centrally acting muscle relaxer)